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Page 4 of 12 Miller et al. Mini-invasive Surg 2021;5:24 https://dx.doi.org/10.20517/2574-1225.2021.25

[28]
IRCC, Hussein et al. 2017 RARC only Retrospective Multicenter Incidence of early oncologic failure (any disease Recurrence patterns, adherence to oncologic principles,
relapse < 3 mo s/p RARC) predictors of early oncologic failure
[29]
ERUS, Collins et al. 2017 RARC, ICUD only Retrospective Multicenter RFS Recurrence patterns
[30]
IRCC, Raza et al. 2015 RARC only Retrospective Multicenter 5-year RFS, CSS, OS Surgical margin, lymph node yield, predictors of survival
[31]
IRCC, Hellenthal et al. 2011 RARC only Retrospective Multicenter Proportion of RARC w/lymphadenectomy Lymph node yield, predictors of lymphadenectomy
performed performance
[32]
IRCC, Hellenthal et al. 2010 RARC only Retrospective Multicenter Surgical margin status Predictors of surgical margin status

RAZOR: Randomized open vs. robotic cystectomy; ORC: open radical cystectomy; RARC: robotic assisted radical cystectomy; RCT: randomized controlled trial; TTR: time to recurrence; RFS: recurrence free survival;
PFS: progression free survival; CSS: cancer specific survival; OS: overall survival; CORAL: controlled three-arm trial of Open, Robotic, and laparoscopic radical cystectomy; RACE: radical cystectomy evaluation;
HRQOL: health-related quality of life; IRCC: International Robotic Cystectomy consortium; LRFS: local recurrence free survival; DMFS: distant metastasis free survival; ICUD: intracorporeal urinary diversion; ERUS:
European Association of Urology Robotic Urology Section; LRC: laparoscopic radical cystectomy.

Since then, multiple RCTs and retrospective comparative studies offer additional insight that robotic cystectomy can meet these standards of surgical quality.
The RAZOR trial showed overall PSM rates of 5% (ORC) vs. 6% (RARC), P = 0.6 without any difference in pathologic stage between the groups. Of those with

PSMs, 7/9 (78%) in RARC and 5/7 (71%) in ORC were T3 or above . Two smaller RCTs also found no difference in PSM rate between open and robotic
[6]
approaches . A meta-analysis compiling 541 patients from RCTs showed no difference in PSM rates between RARC and ORC (RR = 1.2; 95%CI: 0.6-2.4) .
[8,9]
[37]
Additionally, one non-randomized comparative study found significantly increased PSM rate for ORC (18%) vs. RARC (6%) in an inversed probability
weighted population despite similar pathologic staging, though when further specified by site of positive margin these results were not significantly
different . Multiple other non-randomized comparative studies have not found significant differences in PSM rate by approach [13-17,19,20,22-24] .
[12]

Collectively, the above data suggest favorable PSM rates are achievable via the robotic platform and are in alignment with standards of surgical quality set forth
by best practices statements . Regardless of surgical approach, the largest determinant of PSM rates is local disease stage.
[34]

RECURRENCE PATTERNS
Recurrence of bladder cancer after radical cystectomy is dependent on tumor and nodal stage, and ranges from 20% to 30% in pT2 disease, 40% for pT3, > 50%

for pT4 and approximately 70% in pN1 disease or greater . Other independent predictors of tumor recurrence include lymphovascular invasion and positive
[42]
soft tissue margins . Recurrences generally occur within the first 2-3 years and predict worse overall survival (OS) .
[44]
[43]

Recurrence is generally classified as local, often referring to the cystectomy bed and within the pelvic lymph node template, or distant. Atypical patterns in MIS
generally refer to peritoneal carcinomatosis, abdominal wall/port site metastases and extra pelvic lymph node recurrences, which have been described but are
rare. In fact, a systematic review of 1094 studies found only 5 that reported port site metastasis . Proposed contributors of atypical recurrence patterns in MIS
[45]
include depressive local immunologic factors and/or enhanced tumor dissemination related to pneumoperitoneum, breach of oncologic operative principles,